S3-Leitlinie der Deutschen Gesellschaft für Ernährungsmedizin (DGEM) in Zusammenarbeit mit der GESKES und der AKE

Zusammenfassung

Fragestellung: Künstliche Ernährung im ambulanten Bereich umfasst die heimparenterale Ernährung (HPE) und heimenterale Ernährung (HEE) sowie die supplementäre Trinknahrung (ONS), die bei Patienten zu Hause oder in Pflegeeinrichtungen durchgeführt wird. Meistens beginnen HPE/HEE im Anschluss an einen stationären Aufenthalt in einer Klinik. Die vorliegende Leitlinie soll evidenzbasierte Empfehlungen zur künstlichen Ernährung im ambulanten Bereich geben.

Methodik: Es wurde eine systematische Literaturrecherche zur HEE, HPE und zu ONS im ambulanten Bereich durchgeführt. Die Ergebnisse wurden in einer interdisziplinären Arbeitsgruppe aus Medizinern, Apothekern, Ernährungswissenschaftlern und Diätassistenten diskutiert. Auf dieser Basis wurden von der Arbeitsgruppe Empfehlungen erarbeitet, die auf der Konsensuskonferenz am 1. Dezember 2012 vorgestellt, diskutiert, zum Teil modifiziert und verabschiedet wurden.

Ergebnisse: Die Leitlinie enthält 54 Empfehlungen zur künstlichen Ernährung im ambulanten Bereich. Die Indikation zur künstlichen Ernährung im ambulanten Bereich unterscheidet sich nicht grundsätzlich von der Indikation im stationären Bereich, wobei die Aspekte Prognose, Lebensqualität und Ethik im ambulanten Bereich einen besonders hohen Stellenwert haben. Der geeignete Zufuhrweg für eine ambulante künstliche Ernährung hängt von der funktionellen Integrität des Magen-Darm-Trakts ab. Bei einer längerfristigen HEE soll eine perkutane endoskopische Gastrostomie (PEG)-Sonde gegenüber den herkömmlichen chirurgischen Gastrostomieverfahren aufgrund einer niedrigeren Komplikationsrate bevorzugt werden. Bei relevanten Störungen der Transport- oder Absorptionskapazität des Dünndarms soll eine intravenöse Ernährung gewählt werden. Die Pflege der Zugangswege bei HEE und HPE sollte durch geschultes Pflegefachpersonal gemäß evidenzbasierten Richtlinien und Pflegestandards durchgeführt werden, um eine hohe Hygienequalität zu erreichen. Für die ausschließliche und langfristige HEE über gastrointestinale Sonden und für die orale Ernährung durch Trinknahrung sollen vollständig bilanzierte Trink- bzw. Sondennahrungsprodukte verwendet werden, da diese in ihrer Zusammensetzung den D-A-CH-Empfehlungen entsprechen und den EU-Richtlinien genügen. Zur HPE sollten „All-in-One-Nährmischungen“ bzw. „Dreikammerbeutel“ verwendet werden, denn sie sind als sichere, effektive und risikoreduzierende Standards zur Durchführung der HPE etabliert.

Schlussfolgerung: Die HEE und HPE sind anerkannte und sichere Verfahren, wenn sie standardisiert nach aktuellen wissenschaftlichen Erkenntnissen und koordiniert möglichst durch ein interdisziplinäres Ernährungsteam erfolgen. Durch das Ernährungsteam können die Qualität der Maßnahmen erhöht und die Komplikationsraten reduziert werden. Die künstliche Ernährung im ambulanten Bereich kann einen entscheidenden Beitrag zur Verbesserung der Lebensqualität von unterernährten Patienten und zur Steigerung der Kosteneffizienz medizinischer Maßnahmen beitragen.

Abstract

Purpose: Nutritional support in the homecare and outpatient sector comprises home parenteral nutrition (HPN) and home enteral nutrition (HEN) as well as oral nutritional supplements (ONS), being administered in the patientʼs home or in nursing homes. In most cases the HPN/HEN starts following an in-patient treatment in hospital. The present guideline offers evidence-based recommendations for nutritional support in the outpatient or homecare sector.

Methods: A systematic literature search about HEN, HPN, and ONS in the homecare sector was conducted. The results were discussed in an interdisciplinary working group that consisted of physicians, pharmacists, nutrition scientists and dietitians. Based on this discussion and the literature, the working group developed recommendations, which were presented, discussed, partly modified and finally passed at the consensus conference on December 1st, 2012.

Results: The guideline includes 54 recommendations for nutritional support in the outpatient sector. The indication for nutritional support in the outpatient sector does not differ basically from the indication for the in-patient treatment. Criteria like prognosis, quality of life and ethical considerations play a more important role in the outpatient sector. The appropriate way of administration nutritional support in the homecare setting depends on the functional integrity of the gastrointestinal tract. In case of a long-term HEE a percutaneous endoscopic gastrostomy (PEG) tube should be preferred towards surgical gastrostomy procedures, because of lower complication rates. In case of relevant disorders of transport and absorptive capacity of the small intestine intravenous nutrition should be chosen. The nursing care of the tubes and catheters for HEN and HPN should be carried out by professional care attendants according to evidence-based guidlines and nursing standards in order to achieve a high hygiene quality. For the exclusive and long-term HEN via gastrointestinal tube and for nutritional support by ONS nutritionally complete formula (“balanced diets”) should be used because they meet the D-A-CH recommendations and EU guidelines. For HPE, all-in-one bags/three-chamber-bags should be used because these are considered as safe, effective and risk-reducing standards for HPN.

Conclusion: HEN and HPN are accepted as safe procedures, if they are performed following standardized routines according to up-to-date scientific evidence, and if they are coordinated preferably by an interdisciplinary nutrition support team (NST). The NST can enhance the quality of treatment and reduce complication rates. Nutritional support in the homecare and outpatient sector can contribute substantially to an improvement of the patientʼs quality of life and of cost efficiency of medical procedures.

Schlüsselwörter

Leitlinie - ambulanter Bereich - heimenterale Ernährung - heimparenterale Ernährung - orale Trinknahrung - Ernährungsteam

Keywords

guideline - outpatient and homecare sector - home enteral nutrition - home parenteral nutrition - oral nutritional supplements - nutrition support team

^* DGEM Steering Committee: Bischoff SC, Lochs H, Weimann A, Adolph M, Ockenga J, Sieber C

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